What Underlies State Government Performance in Scaling Family Planning Programming? A Study of The Challenge Initiative State Partnerships in Nigeria.

INTRODUCTION: Relatively few studies rigorously examine the factors associated with health systems strengthening and scaling of interventions at subnational government levels. We aim to examine how The Challenge Initiative (TCI) coaches subnational (state government) actors to scale proven family planning and adolescent and youth sexual and reproductive health approaches rapidly and sustainably through public health systems to respond to unmet need among the urban poor. METHODS: This mixed-methods comparative case study draws on 32 semistructured interviews with subnational government leaders and managers, nongovernmental organization leaders, and TCI Nigeria staff, triangulated with project records and government health management information system (HMIS) data. Adapting the Consolidated Framework for Implementation Research (CFIR), we contrast experience across 2 higher-performing states and 1 lower-performing state (identified through HMIS data and selected health systems strengthening criteria from 13 states) to identify modifiable factors linked with successful adoption and implementation of interventions and note lessons for supporting scale-up. RESULTS: Informants reported that several TCI strategies overlapping with CFIR were critical to states' successful adoption and sustainment of interventions, most prominently external champions' contributions and strengthened state planning and coordination, especially in higher-performing states. Government stakeholders institutionalized new interventions through their annual operational plans. Higher-performing states incorporated mutually reinforcing interventions (including service delivery, demand generation, and advocacy). Although informants generally expressed confidence that newly introduced service delivery interventions would be sustained beyond donor support, they had concerns about government financing of demand-side social and behavior change work. CONCLUSION: As political and managerial factors, even more than technical factors, were most linked with successful adoption and scale-up, these processes and systems should be assessed and prioritized from the start. Government leaders, TCI coaches, and other stakeholders can use these findings to shape similar initiatives to sustainably scale social service interventions.

Scaling Access to Contraception for Youth in Urban Slums: The Challenge Initiative's Systems-Based Multi-Pronged Strategy for Youth-Friendly Cities.

INTRODUCTION: More than half of all adolescents globally live in Asia, with India having the largest adolescent population in the world at 253 million. In sub-Saharan Africa, adolescents make up the greatest proportion of the population, with 23% of the population aged 10-19. And these numbers are predicted to grow rapidly-particularly in urban areas as rural youth migrate to cities for economic opportunities. While adolescents and youth are subject to high sexual and reproductive health risks, few efforts have been documented for addressing these in urban settings, especially in poor settlements. METHODS: The Challenge Initiative (TCI) is a demand-driven, family planning platform for sustainable scale and impact that lets city governments-in particular urban slums-lead implementation. It is currently active in 11 countries in Africa and Asia. In June 2018, TCI heightened its focus on adolescent and youth sexual and reproductive health (AYSRH) for youth living in urban slums. It now supports 39 city governments. TCI dedicates technical and program support to married (including first-time parents) and unmarried youth ages 15-24 years. Using an innovative coaching model and an online learning platform (TCI University), TCI supports city governments as they implement AYSRH interventions to accelerate the impact of TCI's model for rapid scale. RESULTS: TCI has been assessing the performance of cities implementing its AYSRH approaches using its RAISE tool and has found considerable improvement over two rounds of assessments through TCI coaching and support for adaptation of its high-impact interventions between the first and second round. CONCLUSIONS: TCI's AYSRH approach scaled rapidly to 39 cities and multiple urban slums since 2018, using its evidence-based interventions and coaching model. In the context of universal health coverage, TCI has supported segmented demand generation and improved access to quality and affordable contraceptive as well as youth-friendly health services. It provides a menu of interventions for cities to implement for youth-including such approaches as public-private partnerships with pharmacies and quality assurance using quick checklists-along with an innovative coaching model. This approach has facilitated greater access to contraceptive methods of choice for youth.